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Free NCLEX-PN Exam Braindumps (page: 11)

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PDF with 1015 Questions

While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?

  1. Ask the parents to allow the infant to lay on her stomach to promote muscle development.
  2. Notify the physician because a developmental or neurological evaluation is indicated.
  3. Document the findings as normal in the nurse’s notes.
  4. Explain to the parents that their child is likely to be mentally retarded.

Answer(s): B

Explanation:

Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation.
Laying the infant on her stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. These findings are not normal for a 6- month-old infant.
Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurologic and other metabolic disorders. Some of those disorders might have mental retardation as a component.
However, this child needs to have the referral to determine the cause of the head lag first.



A preschooler has successfully completed the test item “counts 5 blocks” on the Denver II test. This pass is evidence of which of the following developmental concepts?

  1. centration
  2. causality
  3. nonreversibility
  4. conservation

Answer(s): D

Explanation:

The ability to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn’t change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper or moved to the paper.
Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another.
Nonreversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.



After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

  1. maintaining adequate tissue perfusion
  2. demonstrating behaviors that reduce fears
  3. restored body integrity
  4. remaining free of infection

Answer(s): C

Explanation:

A sense of restored body integrity is an expected outcome for interventions related to disturbed body image. Adequate tissue perfusion is an outcome for risk of injury and risk of infection, not disturbed body image.
Demonstrating behaviors that might reduce fears is an outcome for anxiety. Remaining free of infection is an outcome for risk of infection.



When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

  1. grief work facilitation
  2. vital signs monitoring
  3. medication administration: skin
  4. anxiety reduction

Answer(s): A

Explanation:

Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The expected outcome is grief resolution.
Vital signs monitoring is a nursing intervention classification for deficient fluid volume in clients with major burns.
Medication administration: skin is a nursing intervention classification for impaired skin integrity for clients with major burns.
Anxiety reduction is a nursing intervention classification for anxiety experienced by clients with major burns.






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